CONTRACTORS STATE LICENSE BOARD 9821 Business Park Drive, Sacramento, CA 95827-1703 Mailing Address: P.O. Box 26000, Sacramento, California 95826-0026
STATE OF CALIFORNIA 1-800-321-CSLB (2752) www.cslb.ca.gov
Bond of Qualifying Individual Exemption Certification for Responsible Managing Officer or Qualifying Partner
If you own less than 20% of each firm for which you are the Responsible Managing Officer (RMO) or Qualifying Partner (QP), you must inactivate your individual license. If you own less than 10% of the voting stock of the corporation for which you are the RMO, you must file a Bond of Qualifying Individual in the amount of $12,500. All Responsible Managing Employees (RMEs) must file a Bond of Qualifying Individual without exception.
STATEMENT OF OWNERSHIP
PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK
_______________________________________________________________________ has owned __________________ %
NAME OF RESPONSIBLE MANAGING OFFICER OR QUALIFYING PARTNER ENTER PERCENTAGE
of the voting stock/equity of ________________________________________________________________________________
BUSINESS NAME AS IT CURRENTLY APPEARS ON THE RECORDS OF CSLB
_______________________________________________________________________ since _______________________ .
LICENSE NUMBER OR PENDING APPLICATION FEE NUMBER DATE
On _________________________ at ____________________________________________________________________________________________________________,
DATE CITY/COUNTY/STATE
I/we certify under penalty of perjury under the laws of the State of California that all statements, answers and representations in this application, including all supplementary statements attached hereto, are true and accurate, and that I/we have reviewed the entire contents of this application. I further certify that the Contractors State License Board will be notified within 90 days of any change in the percentage of voting stock/equity owned by me. Signature of RMO or Qualifying Partner _______________________________________________________________________ Print name ______________________________________________________________________________________________ Notice on Collection of Personal Information
The of cial responsible for the maintenance of this information is the Registrar of Contractors, Contractors State License Board. The information may be transferred to other state or governmental agencies. Individuals have the right to review their own les or records maintained by the agency, unless the records are identi ed as con dential information and exempted by Section 1798.3 of the Information Practices Act. CSLB collects the personal information requested on this form as authorized by B&P Code § 30 and CCR 816. CSLB uses this information to identify and evaluate applicants for licensure, issue and renew licenses, and enforce licensing standards set by law and regulation. Submission of the requested information is mandatory. CSLB cannot consider your application for licensure or renewal unless you provide all of the requested information. You may review the records maintained by the CSLB that contain your personal information, as permitted by the Information Practices Act. We make every effort to protect the personal information you provide us, however it may be disclosed in response to a Public Records Act request as allowed by the Information Practices Act; to another government agency as required by state or federal law; or in response to a court or administrative order, a subpoena, or a search warrant. For questions about the Department of Consumer Affairs’ privacy policy or the Information Practices Act, contact the Of ce of Privacy Protection, 1625 North Market Blvd., Sacramento, CA 95834, or email privacy@dca.ca.gov.
13A-30 (11/06)